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Peer-reviewedCC BY-NC-ND 4.0Journal of Neurosurgery: Case Lessons

Transvenous embolization via the pterygoid plexus for a direct carotid-cavernous fistula associated with fibromuscular dysplasia: illustrative case

  • Ryunosuke Haruta1
  • Satoshi Murai1,2
  • Masato Maruno1
  • Shodai Yamada1,3
  • Yoshifumi Tao1
  • Yukari Minami-Ogawa1
  • Satoshi Hirai1
  • Satoshi Inoue1
  • Kenji Yagi1,4
  • Tomohito Hishikawa1
4 affiliations
  1. 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
  2. 2Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts
  3. 3Critical Care Medical Center, Nippon Medical School Hospital, Nippon Medical School, Bunkyo-ku, Tokyo
  4. 4Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, Fukuyama, Hiroshima, Japan
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Abstract

BACKGROUND: Fibromuscular dysplasia (FMD) is a nonatherosclerotic arteriopathy that increases the risk of intracranial aneurysm and arterial dissection. Direct carotid-cavernous fistula (CCF) associated with FMD is rare, and the endovascular treatment strategy is not well established.

OBSERVATIONS: A 52-year-old woman developed a high-flow CCF in the setting of bilateral internal carotid artery FMD. Three-dimensional rotational angiography under balloon test occlusion (BTO) enabled precise localization of the fistula proximal to a cavernous-segment aneurysm. Transvenous selective embolization was achieved through the pterygoid plexus, while the transarterial approach through the FMD-affected ICA was performed safely with a flexible distal access catheter.

LESSONS: In FMD-associated CCF, accurate localization of the shunt using BTO and meticulous endovascular technique allowed for safe embolization. The pterygoid plexus proved to be a useful and feasible access route.

https://thejns.org/doi/10.3171/CASE26625

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Cite

BibTeXRIS
BibTeX
@article{haruta2026transvenous,
  title = {{Transvenous embolization via the pterygoid plexus for a direct carotid-cavernous fistula associated with fibromuscular dysplasia: illustrative case}},
  author = {Ryunosuke Haruta and Satoshi Murai and Masato Maruno and Shodai Yamada and Yoshifumi Tao and Yukari Minami-Ogawa and Satoshi Hirai and Satoshi Inoue and Kenji Yagi and Tomohito Hishikawa},
  journal = {Journal of Neurosurgery: Case Lessons},
  year = {2026},
  month = oct,
  doi = {10.3171/case26625},
  url = {https://doi.org/10.3171/case26625},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Transvenous embolization via the pterygoid plexus for a direct carotid-cavernous fistula associated with fibromuscular dysplasia: illustrative case
AU  - Ryunosuke Haruta
AU  - Satoshi Murai
AU  - Masato Maruno
AU  - Shodai Yamada
AU  - Yoshifumi Tao
AU  - Yukari Minami-Ogawa
AU  - Satoshi Hirai
AU  - Satoshi Inoue
AU  - Kenji Yagi
AU  - Tomohito Hishikawa
PY  - 2026
DA  - 2026/10/26
JO  - Journal of Neurosurgery: Case Lessons
DO  - 10.3171/case26625
UR  - https://doi.org/10.3171/case26625
AB  - BACKGROUND: Fibromuscular dysplasia (FMD) is a nonatherosclerotic arteriopathy that increases the risk of intracranial aneurysm and arterial dissection. Direct carotid-cavernous fistula (CCF) associated with FMD is rare, and the endovascular treatment strategy is not well established.  OBSERVATIONS: A 52-year-old woman developed a high-flow CCF in the setting of bilateral internal carotid artery FMD. Three-dimensional rotational angiography under balloon test occlusion (BTO) enabled precise localization of the fistula proximal to a cavernous-segment aneurysm. Transvenous selective embolization was achieved through the pterygoid plexus, while the transarterial approach through the FMD-affected ICA was performed safely with a flexible distal access catheter.  LESSONS: In FMD-associated CCF, accurate localization of the shunt using BTO and meticulous endovascular technique allowed for safe embolization. The pterygoid plexus proved to be a useful and feasible access route.  https://thejns.org/doi/10.3171/CASE26625
SN  - 2694-1902
ER  -